Healthcare providers maintain records for each of the patients that they see. One of the most commonly maintained record is the patient chart. That chart contains information that identifies the patient, often called ADT information. The ADT information may include name, address, age, sex, social security number, patient number, insurer and primary care physician. The patient chart may also be a medical history based upon answers given to the caregiver by the patient as well as on past treatments. In addition to the ADT information there are entries made by the caregiver to record each examination of the patient. These entries include the date of the exam as well as entries concerning symptoms or complaints that the patient reports to the caregiver, observations made by the caregiver, diagnosis, and prescribed treatment. Each report of examination must be signed by the report's author or authors.
The United States Government's Department of Health and Human Services Health Care Financing Administration (HCFA) agency defines guidelines by which reimbursement is made for various levels of service that caregivers provide to patients. The Resource-Based Relative-Value Scale (RBRVS) is a statistically derived measurement scale, developed for HCFA, which assigns relative reimbursement-related values to various medical-practitioner services. Reimbursement values are enumerated as Level-I through Level-V, with Level-I depicting the least complex level of service and Level-V depicting the most complex level of service. The level of complexity is determined from the information entered on the patient chart. The following table depicts one method by which RBRVS billing levels I-V are determined from a patient-chart. The first column lists the categories of information on the chart. For a simple procedure the physician has looked at only two of the patient's systems and examined only two parts of the patient's body. A complex procedure involved a review of 10 systems and 9 body parts as well as obtaining a more detailed patient history.
CATEGORIESSIMPLECOMPLEXChief Complaint11History of Present Illness3 elements4 elementsPast Medical History1 element1 elementSocial History01 (or 0, if 1 Family History)Family History01 (or 0, if 1 Social History)Review of Systems2 systems10 systemsPhysical Examination2 parts9 partsCourse01Medical Decision Making01Impression11Disposition11
In many hospitals the patient charts are reviewed by coders who translate the information on the chart to codes used by the patient's insurer to determine the amount of payment that will be made by the insurer for the service rendered by the hospital. It is not uncommon for an insurer to refuse payment or consider what the doctor believed was a more complex treatment to be a simple treatment. The difference of opinion often results from the fact that the doctor had not entered onto the patient chart sufficient information for the insurer to regard the treatment as more complex. Had the physician realized that more information was required he or she could have entered that information on the chart at the time of the patient examination. Another problem can occur when the coder does not properly interpret an entry on a chart, and therefore codes that entry incorrectly. This may occur if the coder misreads the handwriting on the chart or misinterprets the phraseology used by the physician. One solution to this problem is for the physician to use standard phrases or codes for the procedures that are used. Yet, that solution places a burden on the caregiver to remember or lookup the codes or standard phrases.
A number of medical language processing systems have been developed that structure and/or encode information occurring in textual clinical reports so that the information can be used for automated decision support and for facilitating document manipulation and viewing by the user. For, example, Friedman in U.S. Pat. No. 6,182,029 discloses a system and method that parses text in a patient chart in accordance with certain parameters and then generates a structured output that is more reliable and may include codes as well as standard phrases. While these systems can be useful, they all operate after the entries in the document have been completed and the patient has been discharged.
Healthcare is to a large extent an information-processing activity. Data about a patient's physical condition is collected by the treating physician using various diagnostic techniques, and is evaluated within the framework of his or her medical knowledge to reach the appropriate decision for therapeutic measures or further diagnostic procedures. If this information processing path is to be effectively enhanced by electronic decision support systems, it is inevitable that data will be structured at some time point, ideally at the very moment of data collection. For this structuring to be useful, however, it requires a standard syntax and terminology that is used by all participating healthcare providers. The lack of such a commonly agreed-upon electronic language has so far been a major impediment for rapid development in this field. Health Level 7 (HL7) was founded in 1987 to develop standards for the electronic interchange of clinical, financial, and administrative information among independent healthcare oriented computer systems; e.g., hospital information systems, clinical laboratory systems, enterprise systems, and pharmacy systems. In August 1996, the HL7 Technical Steering Committee authorized the creation of a Standard Generalized Markup Language (SGML) Special Interest Group as part of a larger initiative to integrate SGML into medical informatics standards. “HCML” is a proposed abbreviation for the evolving markup language: “Health Care Markup Language.”
One application of SGML, Hypertext Markup Language (HTML), has revolutionized the world wide web in the way that electronic documents are exchanged. But, another SGML, Extensible Markup Language (XML), is being viewed as better suited to patient records and their storage, retrieval and exchange. This is so because XML provides tags that identify the content of a document independent of document format. Furthermore, the text is both machine readable and capable of being easily read by people. An example of a tagging scheme for an address would read as follows:
<address> <street> <number> 102 </number> <street_name> Fifth Avenue</street_name> </street> <city> New York </city> <state> NY </state> <zipcode>10001 </zipcode> </address>The art has recognized that a document prepared in XML format can be displayed in any of a variety of ways using a program that instructs the computer to look for the tags and then place information within the tags into a specific location on a page and in a particular font and style. As a result XML has been used to identify healthcare documents and even used to identify information within those documents.
Another trend that has been occurring in the healthcare industry is the use of speech recognition software to create patient records. Speech recognition is the field of computer science that deals with designing computer systems that can recognize spoken words. These words are then recorded as text that can be edited, stored or transferred like any text document. Some systems contain features that not only translate spoken words into text, but also use selected words to cause a computer to perform certain actions. For example, saying the word “edit” may cause the speech recognition software to stop recording and translating spoken words while the user reviews and edits the text that has been created. Manufacturers of speech recognition software have made their products available for use in products made by others. Some of those products take the output of the speech recognition engine and arrange the text to create specific documents. Speech recognition systems have been used to create patient charts. However, the charts that have been created using speech recognition are simply text documents.
Yet, another development in the healthcare industry has been the creation of government regulations that restrict access to patient information. Some information that may appear on a patient's chart cannot even be made available to insurers and other third party payers, but those individuals are permitted to see other information on that chart. Consequently, even though the creation of electronic patient charts facilitates transfer of patient information, government regulations restrict access to that information. As a result, there is a need for an electronic charting system that facilitates transfer of information but contains controls that restrict such information to only those entitled to receive it. There is also a need for an electronic system that permits access to information on a patient chart selectively, allowing different people to access different information on the same chart.
The need for a charting system that facilitates collection and transfer of information while controlling access to collected information is not limited to the healthcare field. Legal documents such as contracts may contain both a performance requirements section and a financial details section. Certain employees may have a need to know information in one or the other section, but not both sections. Manufacturing specifications may contain the basic configuration and general composition of a product that can be disclosed to a potential customer as well as tolerances and formulations that the manufacturer does not wish to disclose. Such documents may contain information useful to a distributor but is inappropriate for disclosure to customers or potential customers. There is much interest and activity among manufacturers to post documents on a server for access by customers, distributors and the general public. Many times a manufacturer will create two or three separate versions of the same document, one version containing information not in another version, for example, a distributor version and a customer version. There is a need for a document-creation system that would enable the creator to restrict access to some information in the document to some users while allowing other users to access the entire document.
There is also a need for a document-creation system that checks the document or chart to assure that sufficient information has been entered according to a predetermined standard. Such a system should report to the user collecting the information whether or not the standard has been met at the time the information is entered into the system. Since information normally is entered in a patient chart before the patient is discharged, missing information can be readily obtained and entered into the patient chart.